Fluid management and goal-directed therapy as an adjunct to Enhanced Recovery After Surgery (ERAS)

© 2014, Canadian Anesthesiologists' Society.Optimal perioperative fluid management is an important component of Enhanced Recovery After Surgery (ERAS) pathways. Fluid management within ERAS should be viewed as a continuum through the preoperative, intraoperative, and postoperative phases. Each phase is important for improving patient outcomes, and suboptimal care in one phase can undermine best practice within the rest of the ERAS pathway. The goal of preoperative fluid management is for the patient to arrive in the operating room in a hydrated and euvolemic state. To achieve this, prolonged fasting is not recommended, and routine mechanical bowel preparation should be avoided. Patients should be encouraged to ingest a clear carbohydrate drink two to three hours before surgery. The goals of intraoperative fluid management are to maintain central euvolemia and to avoid excess salt and water. To achieve this, patients undergoing surgery within an enhanced recovery protocol should have an individualized fluid management plan. As part of this plan, excess crystalloid should be avoided in all patients. For low-risk patients undergoing low-risk surgery, a “zero-balance” approach might be sufficient. In addition, for most patients undergoing major surgery, individualized goal-directed fluid therapy (GDFT) is recommended. Ultimately, however, the additional benefit of GDFT should be determined based on surgical and patient risk factors. Postoperatively, once fluid intake is established, intravenous fluid administration can be discontinued and restarted only if clinically indicated. In the absence of other concerns, detrimental postoperative fluid overload is not justified and “permissive oliguria” could be tolerated.

Embodied Prayer: the practice of prayer as Christian theology

This dissertation attempts to retrieve the integration of prayer and theology in the life of the church. Prayer is a spiritual and bodily theological activity that forms Christian identity and virtuous character. The bodily dimension of Christian prayer plays an essential role in theological understanding and moral formation. However, the embodiment of prayer has been mostly neglected in modern academic theology. This study highlights the significance of the body at prayer in theological studies and spiritual formation.

Chapter 1 presents Karl Barth’s theology of prayer as a model of the integration of prayer, theology, and Christian life (lex orandi, lex credendi, lex agendi). However, Barth’s attempt to overcome the dichotomy between theory and practice in theology did not pay much attention to embodiment of prayer. Through ritual studies and phenomenology (Marcel Mauss, Maurice Merleau-Ponty, and Pierre Bourdieu), chapter 2 shows why the bodily dimension of the practice of prayer should be recovered in theology and ministry; then it explains how Christians in the early and medieval church actually prayed with the body, how their bodily actions were understood in their theological paradigms, and how their actions contributed to the formation of Christian character. Chapter 3 narrows the focus to the formation of the heart in the making of Christian character. The practice of prayer has been emphasized not only as an expression of the inner heart of pray-ers but also as a channel of grace that shapes their affections as enduring dispositions of the heart. Furthermore, historically the bodily practice of prayer gave theological authority to the devout Christians who were marginalized in academic theology or ecclesiastical hierarchy, and Chapter 4 presents the lex orandi of praying women who gained their theological knowledge, wisdom, and authority through their exemplary practices of prayer (Catherine of Siena, Mechthild of Magdeburg, Julian of Norwich, Margery Kempe, and Teresa of Avila). These historical examples reveal how Christian communities appreciated and celebrated the theological voices from the margins, which developed from theological embodiments in prayer.

This dissertation concludes that academic theology needs to heed these diverse theological voices, which are nurtured through everyday practice, as an integral part of theological studies. Therefore, it calls for a new paradigm for understanding the relationship between theory and practice in theological education. The integration between theory and bodily practice is necessary for both academic theology and spiritual formation. A more holistic understanding of Christian practices will not only enhance the training of scholars and clergy but also give the laity their own theological voices that will enrich academic theology.